A few weeks ago while driving in my truck, I was, as usual, listening to National Public Radio. And I picked up on a program where some mental health professionals were discussing what they termed “moral injury” in relation to PTSD (Post-Traumatic Stress Disorder), an illness that has become epidemic among our nation’s military personnel, active duty and veterans.
I was struck by the discussion, trying to absorb as much as I could, given that I had tuned in late. Until my December 10 issue of Newsweek contained a feature article on the same subject.
In this week’s blog, with Christmas being less than a week away, my highlighting of that Newsweek article seems somehow appropriate. Here are some excerpts.
“Moral injury is as old as war. It is recognizable in the Iliad and the Odyssey . . . . It’s hidden in the private thoughts of soldiers from every prior American war. It was perhaps first used in the journals of Mac Bica, a Vietnam vet turned philosophy professor. In the 1990’s two more Ph.D’s popularized the idea, describing ‘the psychological burden of killing’ and Homeric betrayal by leaders. The common thread is a violation of what is right, a tear in what some people freely call the soul.”
Referring to certain returnees (in 2003) from the War in Iraq, “they went from the war zone to their front doors in less than a week. Their mental health screening was pro forma: a group of them in a room, some questions, and a long form to fill out. Are you OK? Yes? OK, thank you. Next!”
“In the years that followed, however, more VA doctors began to notice that veterans were deteriorating; by mid-decade the picture was grim: one in five soldiers with PTSD or major depression, one in two veterans who report to the VA, looking for help with their mental health.”
“Bret Litz, a psychiatrist in the VA Boston Healthcare System, noticed something else: the existing treatments for PTSD weren’t enough. In case after case, they failed to improve veterans’ conditions . . . . Litz wondered why. As the wars in Iraq and Afghanistan entered their second halves, he also noticed that while he was trained to hear stories of fear, when he spoke with veterans, what he heard mainly was sadness. There was sadness related to loss, but also sadness he attributed to ‘bearing witness to evil and human suffering . . . seeing death and participating in it.'”
Litz’s observations and concerns were, at the same time, being shared by his colleague, Shira Maguen, a clinical psychologist in the VA San Francisco Healthcare System.
“Looking at the data, Litz says it seemed ‘unequivocally clear’ that the fear model was not enough [for treating PTSD]. In 2009, he joined with William Nash (who served as a combat psychiatrist in the 2004 Battle of Fallujah), Maguen and two others to publish ‘Moral Injury and Moral Repair in War Veterans.'”
” . . . the word killing isn’t something you’ll hear the military discuss. The word doesn’t appear in training manuals or surveys of soldiers returning from combat . . . . But it might also be a public scourge. Maguen found that from Vietnam to today, killing was the strongest or near strongest risk factor for PTSD . . . [it] doubled the risk of suicidal thinking. In veterans of Iraq, killing not only predicted PTSD, but alcohol abuse, marital problems and anger-management issues.” She continues, “As many as one in four killers develop a drinking problem; one in three shows signs of depression. She says she hears some lines repeatedly in clinics: ‘Nothing can prepare you for what it’s really like’; some say, ‘It feels like I’ve lost my soul.'”
According to another study by Dr. Nash, involving some 200 Marines involved in heavy fighting in Afghanistan in 2009-10, “three months after coming home, interviews showed that 15 likely had PTSD linked more closely to guilt than to fear for their lives. Killing is obviously one source of guilt. Another is failing to save a comrade. One prior study of veterans found that surviving a friend in combat is tied to more severe symptoms of grief than losing a spouse, even 30 years later, and even if the spouse died in the last six months.”
“Litz calls this a ‘no-brainer hint’ that loss and moral injury ‘is going to explain a big chunk of why veterans suffer.'”
Accordingly, the departments of Veterans Affairs and Defense have subsequently created support for further research and treatment related to “moral injury” among active duty military personnel and veterans. And, apart from the military, Brite Divinity School at Texas Christian University has created The Center for Soul Repair, an effort to train religious leaders, as well as the public, to respond to moral injury.
While moral injury “isn’t considered an official diagnosis by the VA or the American Psychiatric Association, the framers of the forthcoming Diagnostic and Statistical Manual of Mental Disorders were persuaded to add guilt and shame to the symptoms section of PTSD.” The “cause and effect,” however, hasn’t changed, and thus “fear remains the focus” of PTSD treatment.
“Last year at a national gathering of military personnel and mental health experts, Litz and Nash shared a stage with a Marine lieutenant colonel who told the men he was ‘insulted’ by the term moral injury.” Which is understandable. “If feelings of guilt or sinfulness are recognized as normal reactions to participating in war, what does that mean for [those] sending young men down range? Where does the stain stop? Does it ever?”
“Karl Marlantes went to Vietnam, won the kind of medals that get him free drinks and came home haunted by some of the lives he took. In his 2011 memoir, What It is Like to Go to War, he argues for an end to our chirpy, parade approach to veterans, which he compares to clapping for a surgeon who has just amputated a leg.”
Marlantes advocates, instead, “a ‘solemn parade,’ a recognition of the moral damage we all suffer when we send our fellow citizens into battle, and a willingness to talk about it–good, bad and ugly.” Rather than merely offering a “wan thanks, pushing veterans away . . . and inside themselves,” suffering from “moral injury,” feelings of haunting sadness, guilt or shame.
